Submit a Photo

Authorization for use of my health information for marketing/broadcast/publication.

The My New Beginning program is a service of City Hospital at White Rock.

Submit a Photo

1
Choose File... * Required
Maximum size of 6MB. JPG, GIF, or PNG.
Starting Weight * Required
Weight in Photo * Required
2
First Name * Required
Date of Birth - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Address
Middle Name
Phone Number
City, State
Last Name * Required
Email Address * Required
Zip Code
3
Link to Video (OPTIONAL)
Tell Us Your Story (OPTIONAL)
By Clicking “Agree” I acknowledge that
I have read and understand the terms of this authorization and I have had an opportunity to ask questions about City Hospital at White Rock’s use or disclosure of my health information for marketing and possible use in broadcast or publication. I hereby knowingly and voluntarily authorize City Hospital at White Rock to use or disclose my health information for the purposes stated herein.
Authorization Agreement * Required
- I Agree

Share your story.